Baby boy dies after five hours of delays and blunders at St George’s hospital

09 Feb 2017

A PREMATURE baby died after a shortage of doctors and midwives at one of the country’s biggest hospitals resulted in five hours of missed opportunities to save his life.

Huw Stewart was delivered stillborn at St George’s hospital, Tooting, after staff initially failed to realise his mother Philippa Stewart had gone into labour at 27 weeks. An internal investigation found the “delay in delivery” and failure to act on his weakening heartbeat was the “root cause” of death.

"Junior midwife left to care for four women after locum doctor walked out over pay"

The shocking report, passed to the Standard, said a junior midwife had been placed in an “untenable situation” by having to look after Mrs Stewart and three other women in labour at the same time, meaning their safety “was compromised”.

The midwife had to interrupt an operation in a bid to summon urgent help after the baby’s heartbeat could not be detected, the report said. It also revealed that a locum doctor had walked out — without telling colleagues — after discovering he was to be paid less than he thought.

Details of the case come as the Royal College of Midwives this week warned that NHS maternity services were “reaching crisis point”, with England short of 3,500 midwives.

St George’s, which features in the TV documentary series 24 Hours in A&E, was last year rated “inadequate” by NHS inspectors, though its maternity department was praised.

"Couple offered no grief counselling and St George’s took a year to admit blame"

It offered no bereavement counselling to Mrs Stewart and husband Jonty and delayed accepting blame for almost a year. Six hours after it was approached by the Evening Standard last week, Mrs Stewart’s solicitors were told that “liability is admitted” and that the trust was preparing “to apologise for this extremely distressing incident”.

Mrs Stewart, 34, told the Standard:

“I’m forever changed by what has happened. I’m definitely not the person I was before we lost Huw.
“I needed someone to say sorry, that we did this terrible thing. That is all I really wanted in the end. It’s sad it has taken a phone call [by the Standard] to progress things. It’s coming up to Huw’s birthday and it’s still unresolved. We can’t focus on moving on. I can’t even think about having another baby.”

Mrs Stewart, who worked as a occupational therapist with children damaged at birth, had been admitted to St George’s on February 13 last year with abdominal pain.

She was kept in overnight and her waters broke about 8am the next day.

The internal review said that delivery should have been recommended at 9.15am. By 10am, “immediate delivery” was required, but this did not happen until 2.11pm.

The report said: “Each time the patient was reviewed after 09.15 there were missed opportunities for intervention.

“The root cause of the stillbirth was the delay in delivery of the baby following incorrect classification of a pathological and preterminal CTG [cardiotocography heart rate scan].”

Mrs Stewart said:

“We didn’t know it was chaotic. We just knew people were not there. I tried a number of times to tell them things were wrong. On my [medical] notes, they label me as anxious, which is quite upsetting.
“I guess the first time we knew things were going terribly wrong was when my waters broke and there was no one around. My husband had to stand in the corridor and shout to get help.”

“That is the whole irony of what happened to us,” Mrs Stewart, an Australian, said. “It would be easy for us to say St George’s is a terrible hospital and tell people to never go there.
“What it shows is what happens when you have a well-funded service with staff on hand. In one hospital there are two completely polar opposite extremes.”

The couple have moved to Melbourne for a “fresh start”.

Their lawyer, Mark Bowman, of Fieldfisher, said:

“The NHS keeps publicly promising better transparency for people experiencing such tragedy.
“Philippa and Jonty had experienced the worst pain possible and were not given the care and compassion any of us would hope for.”

Professor Andrew Rhodes, medical director at St George’s, said:

“This is a very sad case, but one we are committed to learning lessons from.”

This story was orginally report on by Ross Lydall, Health editor and published in the Evening Standard on Wednesday 8 February 2017

About Mark Bowman - The family's Solicitor

Mark joined the award winning Fieldfisher Personal Injury and Medical Negligence team as a trainee in 2003 and was promoted to Partner in 2013. He successfully pursues personal injury claims and medical negligence claims on behalf of victims and their families.